Challenges and innovations in managing a complex giant bilateral juvenile nasopharyngeal angiofibroma with intracranial extension.

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular, benign and locally aggressive tumour that predominantly affects adolescent males. Recognised for its persistence and propensity to recur, patients usually present with gradual development of symptoms such as epistaxis and nasal obstruction over several months to years. Diagnosis typically combines clinical assessments and radiographic studies, often involving preoperative angiography to identify feeder vessels and facilitate embolisation, reducing intraoperative bleeding during surgical interventions. A comprehensive approach to treatment, considering both tumour characteristics and patient well-being, is crucial, particularly when dealing with cases involving intracranial extension. Surgical excision remains the primary treatment for angiofibroma, though radiotherapy is considered for cases with intracranial extension. This case report outlines a case involving a young man in his 20s with a large bilateral JNA extending into the intracranial area. The patient underwent preoperative embolisation followed by surgical resection using a nasofrontomaxillary swing approach with a bifrontal craniotomy window. This alternative approach provided enhanced exposure to address the involvement of the infratemporal fossa, anterior and middle skull base. Postoperatively, residual intracranial tumour was managed with radiation therapy. Over a 2-year follow-up, the patient remains asymptomatic, with a minor postradiation reduction in the intracranial component's size.

A case report: Treatment of a patient with ruptured middle cerebral aneurysm in the second trimester of pregnancy.

BACKGROUND: To summarize the clinical experience of intracranial aneurysm clipping in the treatment of ruptured intracranial aneurysms in the second trimester of pregnancy. METHODS: A case of ruptured middle cerebral aneurysm in the second trimester of pregnancy was reported. Craniotomy and aneurysm clipping were performed at 24 weeks of pregnancy, and fetal preservation was continued after the operation. RESULTS: The prognosis of the parturient was good and the skull was missing on the operative side. A healthy baby boy was delivered by cesarean section 2 months after the operation, and skull repair was performed 4 months after the operation. During the follow-up for 1 year, the mother and son were healthy and no obvious sequelae were found. CONCLUSION: Ruptured intracranial aneurysm hemorrhage in mid-pregnancy is a rare and critical case. Summarizing the corresponding clinical experience will help to have a reference plan for the next time when facing a similar situation, and it will help to treat critically ill patients. The treatment of ruptured intracranial aneurysm in mid-pregnancy requires multidisciplinary collaboration, and cranial aneurysm clamping + fertility preservation can reduce the impact of radiation on the fetus and improve the prognosis for both the mother and the fetus.

Cranioplasty Outcomes from a Tertiary Hospital in a Developing Country.

BACKGROUND: Decompressive craniectomy (DC) is a surgical procedure to treat refractory increase in intracranial pressure. DC is frequently succeeded by cranioplasty (CP), a reconstructive procedure to protect the underlying brain and maintain cerebrospinal fluid flow dynamics. However, complications such as seizures, fluid collections, infections, and hydrocephalus can arise from CP. Our aim is to investigate these complications and their possible risk factors and to discuss whether early or late CP has any effect on the outcome. MATERIALS AND METHODS: A single-center retrospective cohort study was performed, including patients who underwent CP after DC between January 2014 and January 2022. Relevant information was collected such as demographics, type of brain injury, materials used in CP, timing between DC and CP, and postoperative complications. Ultimately, 63 patients were included in our study. We also compared the complication rate between patients who underwent late CP after DC (>90 days) against patients who underwent early CP (<90 days). RESULTS: Most patients were male (78%). The sample median age was 29 years, with pediatric patients, accounting for 36% of the samples. Overall complication rate was 57% and they were seizure/epilepsy in 50% of the patients, fluid collection (28%), infections (25%), posttraumatic hydrocephalus (17%), and bone defect/resorption (3%). Twenty-two percent of patients with complications required reoperation and underwent a second CP. The median (interquartile range) duration between the craniotomy and the CP was 56 (27-102) days, with an early (≤3 months) percentage of 68%. We found no significant difference between early (≤3 months) and late (>3 months) CP regarding complication rates. CONCLUSION: Despite CP being a simple procedure, it has a considerable rate of complications. Therefore, it is important that surgeons possess adequate knowledge about such complications to navigate these challenges more effectively.

Résumé Contexte:La craniectomie décompressive (DC) est une intervention chirurgicale destinée à traiter l'augmentation réfractaire de la pression intracrânienne. La DC est fréquemment remplacée par une cranioplastie (CP), une procédure reconstructive visant à protéger le cerveau sous-jacent et à maintenir la dynamique du flux du liquide céphalo-rachidien. Cependant, des complications telles que des convulsions, des collections de liquides, des infections et une hydrocéphalie peuvent survenir en raison de la CP. Notre objectif est d'étudier ces complications et leurs facteurs de risque possibles et de discuter si une CP précoce ou tardive a un effet sur le résultat.Matériels et méthodes:Une étude de cohorte rétrospective monocentrique a été réalisée, incluant des patients ayant subi une PC après une DC entre janvier 2014 et janvier 2022. Des informations pertinentes ont été collectées telles que les données démographiques, le type de lésion cérébrale, les matériaux utilisés dans la PC, le timing entre la DC et CP et complications postopératoires. Au final, 63 patients ont été inclus dans notre étude. Nous avons également comparé le taux de complications entre les patients ayant subi une CP tardive après une DC (> 90 jours) et ceux ayant subi une CP précoce (<90 jours).Résultats:La plupart des patients étaient des hommes (78 %). L'âge médian de l'échantillon était de 29 ans, les patients pédiatriques représentant 36 % des échantillons. Le taux global de complications était de 57 % et il s'agissait de convulsions/épilepsie chez 50 % des patients, d'accumulation de liquide (28 %), d'infections (25 %), d'hydrocéphalie post-traumatique (17 %) et de défauts/résorptions osseuses (3 %). Vingt­deux pour cent des patients présentant des complications ont dû être réopérés et ont subi une deuxième CP. La durée médiane (intervalle interquartile) entre la craniotomie et la CP était de 56 (27 à 102) jours, avec un pourcentage précoce (≤ 3 mois) de 68 %. Nous n'avons trouvé aucune différence significative entre la PC précoce (≤ 3 mois) et tardive (> 3 mois) en ce qui concerne les taux de complications.Conclusion:Bien que la CP soit une procédure simple, elle entraîne un taux de complications considérable. Il est donc important que les chirurgiens possèdent des connaissances adéquates sur ces complications pour relever ces défis plus efficacement.

Origami-inspired soft fluidic actuation for minimally invasive large-area electrocorticography.

Electrocorticography is an established neural interfacing technique wherein an array of electrodes enables large-area recording from the cortical surface. Electrocorticography is commonly used for seizure mapping however the implantation of large-area electrocorticography arrays is a highly invasive procedure, requiring a craniotomy larger than the implant area to place the device. In this work, flexible thin-film electrode arrays are combined with concepts from soft robotics, to realize a large-area electrocorticography device that can change shape via integrated fluidic actuators. We show that the 32-electrode device can be packaged using origami-inspired folding into a compressed state and implanted through a small burr-hole craniotomy, then expanded on the surface of the brain for large-area cortical coverage. The implantation, expansion, and recording functionality of the device is confirmed in-vitro and in porcine in-vivo models. The integration of shape actuation into neural implants provides a clinically viable pathway to realize large-area neural interfaces via minimally invasive surgical techniques.

Multiple craniotomies in patients with brain metastases: a two-center, propensity score-matched study.

The current study addresses the question of whether the resection of more than one BM by multiple craniotomies within the same operation is associated with more adverse events (AEs) and worse functional outcome compared to cases in which only one BM was resected. All patients who underwent more than one craniotomy for resection of multiple BM at two Swiss tertiary neurosurgical care centers were included. Any AEs, functional outcome, and overall survival (OS) were analyzed after 1:1 propensity score matching with patients who underwent removal of a single BM only. A total of 94 patients were included in the final study cohort (47 of whom underwent multiple craniotomies). There was no significant difference in the incidence of AEs between the single and the multiple craniotomy group (n = 2 (4.3%) vs. n = 4 (8.5%), p = .7). Change in modified Rankin Scale (mRS) and Karnofsky Performance Status (KPS) at discharge demonstrated that slightly more single craniotomy patients improved in mRS, while the proportion of patients who worsened in mRS (16.3 vs. 16.7%) and KPS (13.6 vs. 15.2%) was similar in both groups (p = .42 for mRS and p = .92 for KPS). Survival analysis showed no significant differences in OS between patients with single and multiple craniotomies (p = .18). Resection of multiple BM with more than one craniotomy may be considered a safe option without increased AEs or worse functional outcome.

Minimally invasive keyhole craniotomies for microsurgical clipping of cerebral aneurysms: comparative meta-analysis of the mini-pterional and supraorbital keyhole approaches.

OBJECTIVE: Axel Perneczky is responsible for conceptualizing the "keyhole" philosophy as a new paradigm of minimal invasiveness within cranial neurosurgery. Keyhole neurosurgery aims to limit approach-related traumatization and minimize brain retraction while still enabling the neurosurgeon to achieve operative goals. The supraorbital keyhole craniotomy (SOKC) and minipterional (pterional keyhole, PKC) approaches have become mainstays for clipping intracranial aneurysms. While studies have compared these approaches to the traditional pterional craniotomy for clipping cerebral aneurysms, head-to-head comparisons of these workhorse keyhole approaches remain limited. METHODS: The authors queried three databases per PRISMA guidelines to identify all studies comparing the SOKC to the PKC for microsurgical clipping of cerebral aneurysms. Of 148 unique studies returned on initial query, a total of 5 studies published between 2013 and 2019 met inclusion criteria. Where applicable, quantitative meta-analysis was performed via the Mantel-Haenszel method using Review Manager v5.4 (Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen, Denmark). Risk of bias (ROB) was assessed using the Cochrane ROBINS-I tool, and all studies were assigned a Level of Evidence (I-V). RESULTS: Across all five studies, the mean age ranged from 53.0 to 57.5 years old, and the cohort consisted of more females (n = 403, 60.6%) than males. The proportion of patients presenting with ruptured aneurysmal SAH was comparable between the SOKC and PKC cohorts (p = 0.43). Clipping rate [defined as the rate of successful aneurysm clip deployment with successful intraoperative occlusion] (OR 1.52 [0.49, 4.71], I2 = 0%, p = 0.47), final occlusion rates (OR 1.27 [0.37, 4.32], p = 0.70), and operative durations (SMD 0.33 [-0.83. 1.49], I2 = 97%, p = 0.58) were comparable regardless of approach used. Furthermore, rates of intraoperative rupture (OR 1.51 [0.64, 3.55], I2 = 0, p = 0.34), postoperative hemorrhage (OR 1.49 [0.74, 3.01], I2 = 0, p = 0.26), postoperative vasospasm (OR 0.94 [0.49, 1.80], I2 = 63, p = 0.86), and postoperative infection (OR 0.70 [0.16, 2.99], I2 = 0%, p = 0.63) were equivocal across SOKC and PKC cohorts. CONCLUSION: The PKC and SOKC approaches appear to afford comparable outcomes when used for open microsurgical clipping of cerebral aneurysms in select patients with both ruptured and unruptured aneurysms. Both are associated with excellent clipping and occlusion rates, minimal perioperative complication profiles, and favorable postoperative neurologic outcomes. Further investigations are merited so clinicians can further parse out the indications and contraindications for each keyhole approach.

[The Transcranial Approach for Parasellar Meningiomas].

Patients with parasellar meningiomas often initially present with visual impairment. Understanding the surrounding anatomy is essential when preparing for surgery of parasellar meningiomas, as this region includes various crucial neurovascular structures. Historically, invasive craniotomy, such as the orthozygomatic approach or zygotomy, has often been attempted to access the region; however, the use of these invasive approaches has become less common, because of the accumulation of anatomical knowledge, as well as the development of surgical techniques and devices, including the endonasal endoscopic approach. Herein, we summarize how we perform surgery for parasellar meningiomas, and outline tips and pitfalls that could be useful for young residents and trainees who are new to the skull base field.

Accessing the Porcine Brain via High-Speed Pneumatic Drill Craniectomy.

The use of pigs as an experimental animal model is especially relevant in neuroscience research, as the porcine and human central nervous systems (CNS) share many important functional and architectural properties. Consequently, pigs are expected to have an increasingly important role in future research on various neurological diseases. Here, a method to perform an anterior craniectomy through the porcine frontal bone is described. After a midline incision and subsequent exposure of the porcine frontal bone, anatomical landmarks are used to ensure the optimal location of the craniectomy. By careful and gradual thinning of the frontal bone with a rounded drill, a rectangular opening to the dura mater and underlying cerebral hemispheres is achieved. The presented method requires certain surgical materials, including a pneumatic high-speed drill, and some degree of surgical experience. Potential complications include unintended lesions of the dura mater or dorsal sagittal sinus. However, the method is simple, time-efficient, and offers a high degree of reproducibility for researchers. If performed correctly, the technique exposes a large portion of the unaffected pig brain for various neuromonitoring or analyses.

Clinical features and treatment of apoplectic intratumoral hemorrhage of glioma.

OBJECTIVE: The primary objective of this study was to explore the clinical characteristics of apoplectic intratumoral hemorrhage in gliomas and offer insights for improving the diagnosis and treatment of this disease. METHODS: We analyzed the clinical data of 35 patients with glioma and hemorrhage. There were eight cases of multiple cerebral lobe involvement, and 22 cases involved a single lobe. Twenty-one patients had a preoperative Glasgow Coma Scale (GCS) score of ≥ 9 and had a craniotomy with tumor resection and hematoma evacuation after undergoing preoperative preparation. A total of 14 patients with GCS < 9, including one with thalamic hemorrhage breaking into the ventricles and acute obstructive hydrocephalus, underwent craniotomy for tumor resection after external ventricular drainage (EVD). One patient had combined thrombocytopenia, which was surgically treated after platelet levels were normalized through transfusion. The remaining 12 patients received immediate intervention in the form of craniotomy hematoma evacuation and tumor resection. RESULTS: We performed subtotal resection on three tumors of thalamic origin and two tumors of corpus callosum origin, but we were able to successfully resect all the tumors in other locations that were gross total resection Pathology results showed that 71.43% of cases accounted for WHO-grade 4 tumors. Among the 21 patients with a GCS score of ≥ 9, two died perioperatively. Fourteen patients had a GCS score < 9, of which eight patients died perioperatively. CONCLUSIONS: Patients with a preoperative GCS score ≥ 9 who underwent subemergency surgery and received aggressive treatment showed a reasonable prognosis. We found their long-term outcomes to be correlated with the pathology findings. On the other hand, patients with a preoperative GCS score < 9 required emergency treatment and had a high perioperative mortality rate.

Treatment of recurrent trigeminal neuralgia after microvascular decompression: How to select.

BACKGROUND: This study aimed to investigate individualized treatment strategies and clinical outcomes in patients with recurrent trigeminal neuralgia after undergoing microvascular decompression (MVD). METHODS: One hundred forty-four patients with recurrent trigeminal neuralgia after MVD were retrospectively examined and grouped according to treatment. Surgical efficacy and pain recurrence were analyzed as outcomes. RESULTS: Repeat craniotomy was performed in 31 patients (21.5 %), percutaneous balloon compression (PBC) in 67 (46.5 %), and radiofrequency thermocoagulation (RFT) in 46 (32.0 %). Effectiveness did not differ among the three types of treatment (P = 0.052). The incidence of postoperative complications, including trigeminal nerve cardiac reflex, facial numbness, and mastication weakness, was lower in the craniotomy group than the PBC and RFT groups (P < 0.001). The 5-year pain recurrence rate was significantly higher than the 1-year rate in all groups. Although the 1-year pain recurrence rate did not differ among the groups, the 5-year rate was significantly lower in the repeat craniotomy group than the other groups (P < 0.001). CONCLUSION: Patients with recurrent trigeminal neuralgia after MVD should be treated based on imaging evaluation and general condition. Repeat craniotomy, PBC, and RFT are all effective. Incidence of postoperative complications and long-term pain recurrence-free survival are superior for repeat craniotomy.

A novel theory for rapid localization of the transverse-sigmoid sinus junction and "keyhole" in the retrosigmoid keyhole approach: micro-anatomical study, technique nuances, and clinical application.

To determine a rapid and accurate method for locating the keypoint and "keyhole" in the suboccipital retrosigmoid keyhole approach. (1) Twelve adult skull specimens were selected to locate the anatomical landmarks on the external surface of the skull.The line between the infraorbital margin and superior margin of the external acoustic meatus was named the baseline. A coordinate system was established using the baseline and its perpendicular line through the top point of diagastric groove.The perpendicular distance (x), and the horizontal distance (y) between the central point of the "keyhole" and the top point of the digastric groove in that coordinate system were measured. The method was applied to fresh cadaveric specimens and 53 clinical cases to evaluate its application value. (1) x and y were 14.20 ± 2.63 mm and 6.54 ± 1.83 mm, respectively (left) and 14.95 ± 2.53 mm and 6.65 ± 1.61 mm, respectively (right). There was no significant difference between the left and right sides of the skull (P > 0.05). (2) The operative area was satisfactorily exposed in the fresh cadaveric specimens, and no venous sinus injury was observed. (3) In clinical practice, drilling did not cause injury to venous sinuses, the mean diameter of the bone windows was 2.0-2.5 cm, the mean craniotomy time was 26.01 ± 3.46 min, and the transverse and sigmoid sinuses of 47 patients were well-exposed. We propose a "one point, two lines, and two distances" for "keyhole" localization theory, that is we use the baseline between the infraorbital margin and superior margin of the external acoustic meatus and the perpendicular line to the baseline through the top point of the digastric groove to establish a coordinate system. And the drilling point was 14.0 mm above and 6.5 mm behind the top point of the digastric groove in the coordinate system.

Exploring optimal microscopic keyhole access to the skull base: an anatomical evaluation of transciliary supraorbital and transpalpebral orbitofrontal craniotomy approaches.

PURPOSE: The past two decades have witnessed the rise of keyhole microscopic minimally invasive surgeries, including the transciliary supraorbital approach (TCA) and transpalpebral approach (TPA), commonly known as the transorbital approach. This study aims to elucidate the nuances, specific indications, and advantages of each approach. METHODS: A series of dissections were conducted on five formalin-fixed, alcohol-preserved cadaver heads. The TCA was performed on one side, and the TPA on the other. Virtual measurements of working angles for both approaches were recorded. Additionally, three clinical cases were presented to illustrate the practical application of the techniques. RESULTS: For TCA, the craniotomy dimensions were 1.7 cm x 2.5 cm (Cranial-Caudal (CC) x Lateral-Lateral (LL)), while for TPA, they measured 2.1 cm x 2.9 cm (CC x LL). The measurements of anterior clinoid processes (ACP) were obtained and compared between approaches. In the TCA, the mean ipsilateral ACP measurement was 62 mm (Range: 61 -63 mm), and the mean contralateral ACP measurement was 71.2 mm (Range: 70 -72 mm). In TPA, these measurements were 47.8 mm (Range: 47 -49 mm) and 62.8 mm (Range: 62 -64 mm), respectively. TCA exhibited an average cranial-caudal angle of 14.9°, while TPA demonstrated an average of 8.3°. CONCLUSION: The anterior cranial fossa was better exposed by a TCA, which also featured shorter operative times, enhanced midline visualization, and a quicker learning curve. Conversely, the middle fossa was better exposed by a TPA, making it an excellent option for middle fossa pathologies, including those in the anterior temporal lobe. After sphenoid bone wing drilling, the TPA offers superior visualization from the lateral to the medial aspect and enhances the CC angle. Additionally, the TPA reduces the risk of postoperative frontalis palsy based on anatomic landmarks. However, the TPA requires a greater cranial osteotomy, and due to unfamiliarity with eyelid anatomy, the learning curve for most neurosurgeons is lengthier for this procedure.

Impact of BrainLab VectorVision Infrared-Based Neuronavigation on Surgical Outcomes in Intracranial Meningioma Patients: A Retrospective Study.

BACKGROUND The BrainLab VectorVision neuronavigation system is an image-guided, frameless localization system used intraoperatively, which includes a computer workstation for viewing and analyzing operative microscopic images. This retrospective study aimed to evaluate the use of the BrainLab VectorVision infrared-based neuronavigation imaging system in 80 patients with intracranial meningioma removed surgically between 2013 and 2023. MATERIAL AND METHODS Data were retrospectively collected from 36 patients with convexity meningioma and 44 patients with parasagittal meningioma between 2013 and 2023. The surgical operation of 40 of these patients was performed with the help of neuronavigation, while the other 40 were performed without neuronavigation. Demographic data, preoperative and postoperative radiologic images, craniotomy measurements, surgical complications, and operative times of patients with and without neuronavigation were analyzed. RESULTS Using neuronavigation significantly increased surgery duration (P=0.023). In 6 patients without the use of neuronavigation, the craniotomy had to be enlarged and this resulted in superior sagittal sinus (SSS) damage (P=0.77, P=0.107). Patients for whom neuronavigation was used did not experience any sinus damage and did not require craniotomy enlargement. Postoperative epidural hematoma (EH) developed in 9 patients without navigation, whereas it developed in only 1 patient with navigation (P=0.104). Residual tumors were less common in patients using navigation (P=0.237). CONCLUSIONS The use of neuronavigation allows the incision and craniotomy to be reduced in size. Intraoperatively, it allows the surgeon to master the boundaries of the tumor and surrounding vascular structures, reducing the risk of complications. These results suggest that neuronavigation systems are an effective ancillary in meningioma surgery.

Experimental Modeling of Cranial Injury and Defect Reconstruction Using Superconstructive Polymers (PEEK).

Experimental model of resection craniotomy with subsequent reconstruction of the defect with a polymer implant enables comprehensive assessment of functional and ultrastructural changes during replacement of the damaged tissue. Reconstruction of a skull defect was accompanied by transient motor disturbance in the acute period and did not cause functional disorders and neurological deficits in a delayed period. Histological examination of osteal and brain tissue revealed no pathological reactions that could be associated with the response to the chemical components of the implant.

Suprapterional keyhole approach for anteromedial skull base lesions: How I do it.

BACKGROUND: For a minimally invasive treatment approach to the anteromedial part of the anterior cranial fossa (ACF), a small incision and craniotomy of the posterolateral part of the ACF are preferable. METHOD: We described the concept and technique of suprapterional keyhole approach (SPKA), which uses an exoscope and endoscope to treat ACF lesions. CONCLUSION: The SPKA enables ACF observation from the lateral direction; the endoscope's extended viewing angles enable the observation of the anteromedial part of the ACF, including the bilateral olfactory groove. Facial skin and large scalp incisions are avoided, making this approach efficient for ACF lesions.

Anterior interhemispheric vs. pterional approach in the microsurgical management of anterior communicating artery aneurysms: a comparative analysis employing a novel multidimensional matching-tool.

The surgical management of anterior communicating artery aneurysms (AcomA) is challenging due to their deep midline position and proximity to complex skull base anatomy. This study compares the pterional craniotomy with the interhemispheric approach based on the specific aneurysm angulation. A total of 129 AcomA cases were analyzed, with 50 undergoing microsurgical clipping via either the pterional or interhemispheric approach. All selected cases had computed tomography-angiography with sagittal imaging slices and 2D-angiography. Using an interactive tool, 14 cases treated via the interhemispheric approach were matched with 14 cases approached pterionally based on clinical and morphological parameters, emphasizing intracranial aneurysm (IA) dome angulation relative to the frontal skull base. Outcomes included IA occlusion, temporary clipping incidence, intraoperative rupture, postoperative strokes, hemorrhages, hydrocephalus, vasospasm, and patient functionality. Matched cohorts had consistent demographics. Both approaches resulted in similar IA occlusion rates, but the interhemispheric approach led to improved clinical outcomes, measured by the modified Rankin Scale. It also had a lower incidence of hydrocephalus and reduced need for permanent ventriculoperitoneal shunt placement. Vasospasms and postoperative infarction rates were comparable between the groups. Our findings suggest potential advantages of the interhemispheric approach in managing AcomA, depending on aneurysm angulation. Despite a small sample size, the results highlight the importance of customized surgical decision-making based on the unique traits of each aneurysm and the surgeon's expertise.

Springs Produce Favorable Morphologic Outcomes Relative to H-Craniectomy According to a Two-Center Comparison of Matched Cases.

BACKGROUND: Sagittal synostosis is the most common type of premature suture closure, and many surgical techniques are used to correct scaphocephalic skull shape. Given the rarity of direct comparisons of different surgical techniques for correcting craniosynostosis, this study compared outcomes of craniotomy combined with springs and H-craniectomy for nonsyndromic sagittal synostosis. METHODS: Comparisons were performed using available preoperative and postoperative imaging and follow-up data from the 2 craniofacial national referral centers in Sweden, which perform 2 different surgical techniques: craniotomy combined with springs and H-craniectomy (the Renier technique). The study included 23 pairs of patients matched for sex, preoperative cephalic index, and age. Cephalic index, total intracranial volume (ICV), and partial ICV were measured before surgery and at 3 years of age, with volume measurements compared against those of preoperative and postoperative controls. Perioperative data included operation time, blood loss, volume of transfused blood, and length of hospital stay. RESULTS: Craniotomy combined with springs resulted in less bleeding and lower transfusion rates than H-craniectomy. Although the spring technique requires 2 operations, the mean total operation time was similar for the methods. Of the 3 complications that occurred in the group treated with springs, 2 were spring-related. The compiled analysis of changes in cephalic index and partial volume distribution revealed that craniotomy combined with springs resulted in superior morphologic correction. CONCLUSION: The findings showed that craniotomy combined with springs normalized cranial morphology to a greater extent than H-craniectomy based on changes in cephalic index and total and partial ICVs over time. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.